Washington Middle School Learning Resource Center
Digital / Video Equipment Loan Form
Student’s Name: HR:
Video/DVD Cost $_______ Barcode # :
Canon DV Camera (ZR 45) $400.00 Barcode # :
(includes battery, charger, cables)
Olympus Digital Camera $300.00 Barcode # :
(includes battery, charger)
iBook Laptop $800.00 Barcode # :
Tripod (with plate) $60.00 Barcode # :
Other $ Barcode # :
Date of Loan: Teacher / Class
Please describe the school assignment for which you will be using the equipment:
All equipment must be returned no later than 8:10 A.M. the next school day.
Students will notify LRC staff if they need assistance with equipment.
By signing below the student accepts the responsibility for the safeguard, proper use,
and timely return of the equipment with the understanding that it will not be sub-leased,
loaned, or used to generate any fees, charges, or other income.
By signing below the parent accepts the responsibility for paying the repair /
replacement cost of any equipment that is returned damaged.
Student’s Signature: Date:
Parent / Guardian’s Signature: Date: